Dr. Wessler is Director of the Valve Center at Tufts Medical Center and Assistant Professor of Medicine at Tufts University School of Medicine. He maintains dual appointments in the Division of Cardiology and the Institute for Clinical Research and Health Policy Studies (ICRHPS). His research focus is on older patients with valvular heart disease considering advanced procedures. His long- term goal is to be an independent clinician investigator developing interventions to enhance shared decision-making for high risk older adults. In the proposed research, he will focus on the burden and significance of comorbidities for patients treated with transcatheter aortic valve replacement (TAVR) and understanding how older adults with aortic stenosis (AS) integrate risk information into their decisions. These issues are of central importance since there is inherent uncertainty in clinical predictions and there is significant phenotypic heterogeneity for older adults with AS. Ultimately patients may elect for treatment despite high pre-procedure risk if there is potential for improved quality of life. It is challenging to balance treatment opportunities and the competing risks from comorbidities that may limit life expectancy. In the case of TAVR 24% of treated patients are dead within one year of treatment. Aim 1 of this research will determine the patterns and significance of major comorbidities among older adults treated with TAVR using the OptumLabs data warehouse and determine whether latent class analysis can improve our understanding of this heterogenous patient group. Aim 2 will qualitatively evaluate how older adults with severe AS integrate risk information to make treatment decisions. Dr. Wessler has been long interested in risk prediction in cardiovascular disease and he is now focused on improving understanding about the complex clinical phenotypes that inform prognosis for patients with symptomatic AS. The qualitative study aims to align predictions and risk assessment with information needs of high risk patients considering TAVR. The final goals are to more fully understand the significance of comorbidities for these patients and to improve shared decision-making for TAVR. Dr. Wessler's outstanding mentoring team is multidisciplinary; his mentors and advisors are from the diverse fields of predictive modeling and heterogeneity of treatment effect (Dr. Kent), geriatric medicine and multimorbidity (Dr. Boyd), qualitative research (Dr. Han), clinical trial design (Dr. Udelson), aortic stenosis and TAVR (Dr. Weintraub). The proposed research and training will take place primarily in the productive and supportive environments of Tufts University, where Dr. Wessler has joint appointments. This research is at the intersection of cardiology and geriatric medicine; Dr. Wessler is one of only a handful of cardiology trained clinician investigators focusing in this area. Ultimately, the proposed research and training will give Dr. Wessler the experience and skillset to achieve independence as a clinician investigator dedicated to the improvement of care for older adults with advanced cardiovascular disease.